Diagnosis & Treatment Planning in CD

DR. ABDUL RAZAK

PROF AND HEAD

DEPT. OF PROSTHODONTICS AND CROWN & BRIDGE

MES DENTAL COLLEGE AND HOSPITAL, PERINTHALMANNA

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Introduction

• Diagnosis Comprises of evaluation of patients health with respect to his/her physical, mental & social health, and these diagnostic findings decide treatment plan.
• Treatment planning is the most important milestone which depends on the diagnosis
• Prognosis depends on both diagnosis and treatment planning.

• EDENTULISM - debilitating and irreversible condition and is described as the “final marker of disease burden for oral health

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• Success of Complete Denture treatment depends on thorough diagnosis and proper treatment planning which will satisfy the need of the patient

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Int J Dent. 2013; 2013: 498305.

The Impact of Edentulism on Oral and General Health

Elham Emami, Raphael Freitas de Souza, Marla Kabawat, and Jocelyne S. Feine

DIAGNOSIS

• It is the act or process of deciding the nature of a diseased condition by examination, a careful investigation of the facts to determine the nature of a thing. Or the determination of the nature, location and cause of disease
• heartwell

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• It is the examination of the physical state, evaluation of the mental or psychological makeup, and understanding the needs of each patient to ensure a predictable result.
• Winkler

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• Determination of the nature of the disease
• Glossary of Prosthodontic Terms, Edition 9, J Prosthet Dent 2017;1-105

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• sequence of procedures planned for the treatment of a patient after diagnosis

Treatment Planning

Glossary of Prosthodontic Terms, Edition 9, J Prosthet Dent 2017;1-105

Treatment plans should be developed to best serve the needs of each individual patient.

According to Boucher 4

developing sequence of procedures planned for the treatment of a patient after diagnosis - Winkler

Name

Must for

• Identification
• Building rapport
• Gaining confidence of patient
• For data record keeping

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Age

The apparent age/biological age of a person is far more important than his actual age and is one of the most significant observations one makes.

• Age indicates ability to wear dentures successfully from prosthodontic point of view.

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• In 4th decade we see :-
• Rapid healing of tissues.
• More resilient tissues.
• Ease in patient adaptation to denture.
• Patients are more esthetically concerned.

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In 5th decade onwards :-

No rapid healing.

Tissue not much resilient.

Menopausal hormonal changes make women patients more exacting or hysterical type for esthetics.

Longer learning period because of muscle insufficiency.

Race : disease prevelance

• Characterisation
• Sex : appearance priority - Women > Men – younger males
• Older men – comfort & function
• Menopause – bone & mucosa

Occupation :influences the degree of importance of factors like esthetics, phonetics & general appearance.

Job & social standing determines the value patient gives on his/her dental health/esthetics.

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Address & Telephone no.

• For future correspondence
• To change the appointments
• To maintain a record
• Spouse/family/friend’s contact number in case of emergency
• If the patient lives at a considerable distance from the surgery, can they attend for the number of visits required to make dentures?
• If they rely on a relative or friend to bring them to the surgery, will they be able to come for each and every visit?

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The successful prosthodontic treatment depends on both technical skill & patient management according to mental attitude.

According to Dr. MILUS MARYLSON HOUSE (1960)

Philosophic

• Willing to accept the dentist’s judgement without question.
• Best mental attitude for denture acceptance.
• Motivation is generalized.
• Ideal attitude for successful treatment, provided the biomechanical factors are favorable.

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Exacting

• All good attributes of philosophic patient.
• Require extreme care, effort and patience on the part of the dentist.

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• Methodical, precise and accurate and at times make severe demands.

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• Likes each step of the procedure to be explained.

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• If intelligent and understanding they are the best or else extra hours must be spent, prior to treatment, in patient education until an understanding is reached.

Indifferent Hysterical

• Questionable or unfavorable prognosis.
• Little concern for their teeth or oral health.
• Without dentures or worn out dentures for years.
• Seek treatment because of the insistence of family.
• Pay no attention to instructions, uncooperative & give up easily if problems are encountered with their new teeth.
• Do not value the efforts or skills of the dentist.
• Require more time for instruction on value and use of their dentures.

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Submit to treatment as a last resort, have negative attitude, often poor health, unfounded complaints.

Emotionally unstable, excitable, apprehensive and hypertensive. Unrealistic expectations.(demand equals to natural teeth) Prognosis is often unfavorable.

Additional professional help (psychiatric) is required prior to and during treatment.

Gamer et al.’s classification(2003)

• Gamer’s et al modified house classification because, It uses outdated terminology: eg. term hysterical, has been regarded derogatory and judgemental.
• Hence there is a need for modification
• House classification pertaining to a patient in isolation does not consider codetermining factors.
• Stolorow and Atwood were particularly critical of this aspects of house classification. They called it ‘The MYTH of THE ISOLATED MIND’

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Gamer, S., Tuch, R., & Garcia, L. T. (2003). M. M. House mental classification revisited: Intersection of particular patient types and particular dentist’s needs. The Journal of Prosthetic Dentistry, 89(3), 297–302.

• based on 2 factors.
• Patient engagement
• Willingness to submit
• IDEAL- Good engagement and willingness to submit
• SUBMITTER- excellent engagement and excellent Willingness to submit
• RELUCTANT- average engagement and average willingness
• INDIFFERENT- same as indifferent patient classified by house
• RESISTANT- similar to house exacting patient

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ALAN MACK’S CLASSIFICATION

• Ectomorph- worrying type
• Endomorph- care free type
• Mesomorph- passive type

BLUM’S CLASSIFICATION(1960)

REASONABLE OR REALISTIC: well educated, trust the physician with the diagnosis and treatment plan & are relaxed.

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UNREASONABLE OR UNREALISTIC: less educated, have low income, do not trust the physician, anxious, oversensitive and overcritical.

FRANKEL’S CLASSIFICATION

• Definitely negative behaviour - refusal to treatment.
• Negative- reluctant to treatment.
• Positive - acceptance of treatment
• Definitively positive - enjoy treatment.

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IPWCDO’s classification

• Patients response to complete dentures can be grouped as adaptive and maladaptive response.
• Factors that produce adaptive response are
• Confidence in the dentist
• Previous favourable experiences.
• Positive attitude
• Good physical health and coordination
• Realistic expectations.
• Good learning capacity.
• Desire to please the doctor, good cooperation
• Awareness on the limitations of a complete denture

Factors that produce maladaptive response

• Lack of trust in the dentist.
• Poor communication
• Previous negative experience
• Resistance to change and low tolerance due to high anxiety
• Inadequate tissue tolerance and muscle coordination.
• Chronic dissatisfaction and wish to fail.
• Disapproval of dentures by people are important to the patient.

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Cosmetic index

• speaks about the esthetic expectations of the patient.
• Class 1 - HIGH COSMETIC INDEX -more concerned about the treatment and wonder if their expectations can be fulfilled.
• Class 2- MODERATE COSMETIC INDEX. -patients with normal expectations.
• Class 3 - LOW COSMETIC INDEX - These patients are not bothered about the treatment and aesthetics. It is very difficult for the dentist to know if the patient is satisfied with the treatment or not.

Chief Complaint

• Obtained by asking the patient to describe the problem.
• Should be recorded in patient’s own words as much as possible.

Medical history

• Name of the physician, including data &reason for last appointment.
• A record of status of all major systems of body.
• A record of all medications the patient is currently taking.
• A record of any hospitalization.
• A record of any complication that was result of previous dental treatment.
• A record of patient opinion of his/her general health.
• Space to update health history whenever patient is recalled.

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• Systemic diseases might or might not have oral manifestation but some have a direct relation to denture success these are:-
• Debilitating disease

debilitating diseases includes diseases like diabetes , tuberculosis , blood dyscrasias etc.

• These patients require extra instructions in oral hygiene, eating habits & tissue rest.
• Physician Consultation
• Frequent recall appointments to check the status of the underlying bone & occlusion

Diabetes Mellitus

• A metabolic disorder due to lack or resistance to insulin.
• Shorter appointments preferably in mornings
• Mucostatic impression technique
• Dentures with small food table
• Use of soft denture liners.
• Instructions for maintaining denture hygiene
• Frequent evaluation of denture is necessary

• An uncontrolled or poorly controlled diabetics may pose problem of:
• Bacterial viral & fungal infections including candidiasis.
• Xerostomia- it causes dry atrophic oral mucosa accompanied by mucositis,
• ulcers, desquamation & opportunistic infection.
• Inflamed , depapillated painful tongue.
• Difficulty in lubricating , masticating & swallowing are the complications that make denture wearing a bad experience.
• Poor wound healing / multiple abscess
• Burning mouth syndrome

Oral Tuberculosis

• tongue is most commonly affected.
• Other sites include the palate, lips, buccal mucosa, gingiva, palatine tonsil, and floor of the mouth. Salivary glands, tonsils, and uvula are also frequently involved.
• Primary oral TB - painless ulcers of long duration and enlargement of the regional lymph nodes
• Ulcers, nodules, tuberculomas, and periapical granulomas
• Superficial ulcers, patches, indurated soft tissue lesions, or TB osteomyelitis or simple bony radiolucency

Tuberculosis

• Can be transmitted from patient to dentist and laboratory personnel

Following precaution should be taken:

• Wear gloves, mask and eye protection glasses.

• Instrumentation should be sterilized completely and aseptic

procedures strongly advocated.

• If possible, disposable things should be used in the treatment.
• Efficient denture are necessary as diet is important in treatment.

• .Denture should be checked often for infection
• Operating air should be vented out .
• Oral lesions may make use of prosthesis difficult .

Osteoarthritis

• <45 yrs. of age, men > women.
• 45-65 yrs. women affected more.
• >65 yrs. both affected equally.
• Normally affects weight bearing joints &secondarily TMJ.
• If terminal finger joints become arthritic, it is difficult to clean or insert dentures.

• mandibular movements are painful &jaw relation records are difficult to record
• Occlusion correction must be made often because of subsequent change in joint.
• Special impression trays are necessary due to limited access from reduced mouth opening.
• In extreme cases surgery may be required
• Reduction of the forces on residual ridge
• Mucostatic or open mouth impression techniques, selective pressure impression technique
• semi anatomic or non anatomic teeth with narrow buccolingual width
• Optimal use of softliners, extended tissue intervals by keeping the dentures out of mouth for 10 hours a day can be advised

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Journal of Clinical and Diagnostic Research. 2015 Dec, Vol-9(12)

ACROMEGALLY

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Excess of growth hormone produced after epiphyseal plate closure at puberty

Enlargement of the hands, feet, nose and ears; expansion of the skull

Mandibular protrusion, spacing of the lower teeth and macroglossia.

Necessitates a multidisciplinary approach

Follow-up care for acromegalic

Frequent review appointments needed to ensure the acceptance and accommodation to new removable dentures.

Eur. J. Prosthodont. Rest. Dent., Vol.22, No. 3, pp 98-100

Cardiovascular disease

Includes ischemic heart disease(angina), arterial hypertension, arrhythmias, myocardial infarction & chronic heart failure.

Consultation with patients cardiologist is indicated

Surgical procedure of any nature may be contraindicated

Short appointments with pre- medication

ACE inhibitors : - Erythema Multiforme, Xerostomia, Loss Of Taste, Pharyngitis, Burning Sensation & Ulcers.

β- blockers : Xerostomia, Paresthesia.

Calcium antagonists (nifedipine) : Gingival Hyperplasia, Sialorrhea

Diuretics : Xerostomia, Parotid Gland Hypertrophy.

Dent Clin N Am 50 (2006) 483–491 – ischemic heart diseases & their management. James R. Hupp

• Prosthetic Management
• •Communicate with the patient’s physician.
• •Reduce patient’s stress and anxiety.
• •Morning appointment.
• •Reassurance & peaceful environment. 55

•Avoid surgical procedures if possible.

•If not, perform it under proper antibiotics coverage.

•Postpone procedures for at least 6 months if not very necessary.

•Do not treat patient with coronary bypass until at least 2 weeks after operation.

•Always ready with emergency kit & services for an immediate control.

DISEASES OF THE SKIN

Skin diseases like Pemphigus have oral manifestations, which vary, from ulcers to bullae.

Make denture use impossible without medical treatment.

Constant use of the prosthesis should be discouraged for these patients.

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Herpes

• Recurrent intra oral herpes
• Herpes zoster Prosthodontic considerations

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Use of prosthesis - uncomfortable

Care taken to avoid herpetic whitlow

HYPERTENSION

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Oral side effects of antihypertensive medicines

Diuretics - Dry mouth, lichenoid reaction

Beta blockers - Dry mouth, taste changes, lichenoid reaction

ACE inhibitors - Loss of taste, dry mouth, ulceration, angioedema

Calcium channel blockers - Gingival enlargement, dry mouth, altered taste

Alpha blockers - Dry mouth

Direct-acting vasodilators - Facial flushing, possible increased risk of gingival bleeding and infection

Central-acting agents - Dry mouth, taste changes, parotid pain

Angiotensin 2 antagonists- Dry mouth, angioedema, sinusitis, taste loss

Orthostatic hypotension- antihypertensives, antidepressants, centrally acting skeletal muscle relaxants.

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Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension.Bruce Bavitz

PROSTHETIC MANAGEMENT

Fabricating a complete denture - avoid causing soft tissue abrasion.

Denture adhesives and artificial saliva may aid in the retention of the prosthesis.

In such patients artificial salivary lubricants should compensate the effect of xerostomia

International Journal of Sciences: Basic and Applied Research (IJSBAR)(2015) Volume 20, No 1, pp 260-265

Facial palsy

• Facial palsy is indicative of neurological involvement.
• Denture retention, maxillomandibular relation records and supporting the musculature are some of the added denture problems.

• Impressions to be recorded with borders intentionally made thicker within the physiological limits, on the affected side to support the flaccid musculature.
• Flaccid facial muscles needed support - (cheek plumper) .
• Zero-degree posterior teeth selected as they have the advantages of simplest recordings and a wide range of tooth positions possible; further no lateral stresses on the underlying structures and are easier to control for patients with uncoordinated closures.

Parkinson’s disease

• Is a progressive neurological disorder with resting tremor, bradykinesia, akinesia, and postural instability. The psychological components of disease include depression, anxiety, and cognitive deficiency.
• The orofacial findings of these patients include mask-like face, impaired speech, xerostomia, and dysphagia with saliva drooling from the corner of mouth..

• Although PD patients drool, they actually produce less saliva than normal age counterparts.

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• The successful complete denture rehabilitation largely depends on the ability of the patient to control the denture with oral musculature. The denture retention and control in PD patients is further compromised due to thick ropey saliva, xerostomia, and rigid muscles

Management

• Dentist should introduce him/herself every appointment with a compassionate, caring approach. The stress is known to exacerbate the tremor and uncontrolled movement during treatment.
• caregiver’s presence beside the patient is also helpful.
• short, mid-morning appointments are ideal
• implant or tooth-supported over dentures are advantageous for better proprioception and controlled jaw movement

Drug history

• Dentist should know all the medicines

patient takes because:-

• It indicates systemic diseases the patient is suffering from & this could alter dental treatment
• Compatibility of dentist’s prescribed medicines & physician should be there.
• Conditions which affect the prosthodontic treatment & the drugs causing them.

Dental history �

• Cause for the tooth loss
• Period of edentulousness
• Problems with existing denture
• Expectations in new denture

• Period of edentulism

Gives information about the amount and pattern of bone resorption

• Cause of loss of teeth:

• Periodontal: implies the reduced potential ridge structure available for denture support
• Caries :one may be spared and optimal bone support may be

expected if caries did not cause complications like alveolar abscess.

• Congenital: congenital absence of teeth, impaired bone supported ectodermal dysplasia
• Trauma: it may cause complications in prosthetics because of
• Bone loss
• scar tissue
• irregular ridges or shortened ridges,
• altered maxillo -mandibular ridge relationship

History of previous/ existing

dentures

• A provide key information which leads to a sound diagnosis and an effective treatment plan. Patients requesting replacement dentures fall into three broad categories.

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1. wearing immediate dentures
2. most recent dentures have been worn successfully for a significant period of time
3. with dentures that have caused persistent problems from the very beginning

History Of Previous

Denture

• Duration
• Denture care
• Stability
• Retention – border extension and thickness
• Esthetics
• Vertical dimension of occlusion
• Phonetics
• Denture hygiene
• Occlusion.

Reason for replacement of Denture

• The patient’s concerns regarding their current dentures and their aspirations for treatment must be assessed.
• Reason for replacing dentures.

Problems with

-Mastication

-Phonetics

-Esthetics

-Fit

• Ithis problem longstanding or of recent onset?
• How long have they been edentulous?
• How many sets of complete dentures have they had in the past?

1. General Appearance

Does the patient appear healthy?

Does the patient show signs of proper nourishment?

Nodules, nevi, ulcerations, enlarged lymph

nodes if any should be noted.

2. Facial Examination

Facial symmetry

• Does the face appear symmetric or asymmetric?
• Outline form of face important for the

selection of tooth shape.

Extraoral examination

Facial form

• Examining the facial form helps in teeth selection.
• General outline of the tooth should confirm to the general outline of the face when viewed from the frontal aspect

Classification of (frontal) face form

House and Loop, Frush and Fisher and William’s classified face

form as:

A. Square

C. Tapering

B. Square-tapering

D. Ovoid

Facial profile

Classification of the facial profile (lateral face form) – Angles Classification

Class I – Normal

Class II – Retrognathic

Class III – Prognathic

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determines the jaw relation and occlusion.

• Sit upright
• Wet the lips
• Place them into light contact and
• Relax

• Face should be observed by a side view.

• Profile is assessed by joining two reference lines-

1- A line joining the forehead and the deepest point in the curvature of upper lip (Subspinale)

2- A line joining subspinale and most anterior point of the chin(pogonion).

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COMPLEXION

• With age, skin becomes thinner and melanin pigmentation accumulates in skin leading to darker in shade with age. (Heartwell)
• hair, eye and skin color provide useful guides in shade selection.
• Skin color can also reveal underlying disease and pathology
• Pallor – indicative of anemia, hypothyroidism, or nephrosis
• or may be due to lack of nourishment
• Ruddy complexion – polycythemia, neoplasm, chronic alcoholics
• Bronzed skin – Addison’s disease or may signify that patient
• is receiving or has received radiation therapy

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• Diffuse bluish purple color – may indicate vitamin B2 deficiency or drug reaction
• Color changes of cyanosis vary from bluish purple to red

purple

• Lemon yellow complexion –jaundice, liver cirrhosis , gall stones
• Increase in pigmentation – sometimes caused by adrenal

gland insufficiency

Muscle tone

Affects the stability of the denture.

House classified the muscle tone as:

• Class I: Tissues are normal tone & function.
• Complete edentulous patients mostly donot have class 1 musculature – degenerative changes
• Seen in immediate dentures

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• Class II: Normal muscle function but slightly decreased muscle tone.
• In patients wearing dentues with correct vertical height

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• Class III: Decreased muscle tone and function.
• ill-fitting dentures, decreased vertical dimension

• Muscle development

house classification

• Class 1 – heavy
• Class 2 – Medium or normal
• Class 3 – Light

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Greatly impaired muscle tone and function

Usually is coupled with –

• poor health,
• inefficient dentures,
• loss of vertical dimension
• wrinkles
• Decreased biting force &
• Drooping commissures

NEUROMUSCULAR CONTROL

• House classification
• Class 1

Enough muscular control to use denture effectively and not to exceed physiologic tolerance of denture bearing tissues by putting excessive pressure on teeth.

• Class2

Patient chews with great force.

can cause sore mouth as tissue tolerance limit exceeds.

• Class 3

Slight deviation of muscle coordination .

light chewers and can not control dentures effectively.

Lip fullness

• directly related to the support it gets from the mucosa or denture base and the teeth
• Lip fullness should not be confused with lip thickness, which involves the intrinsic structure of the lip

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• An existing denture with an excessively thick labial flange could make the lip appear to be too full.

Lip length

• will affect how much the teeth will be exposed during rest and function
• short lip

more exposure of the teeth or sometimes denture base also. Seen in incompetent lip

• long lips hide denture base and most of the teeth
• Vertical lip relation: in lower facial height, length of upper lip is

Equal to one third. Length of lower lip plus chin should be two third.

Lip length

• They are classified as :

Long

Normal/Medium

Short.

Short upper lip -10-15mm

Medium Lip-16-25mm

Long lip -26-36 mm

Horizontal lip relation (lip step)�

is A-P relationship of upper to lower

lip

• Normal-lip step is slightly negative
• Positive -lip step positive (seen in class III case)
• Marked negative - seen in class II cases

Lip thickness

• because of intrinsic structure of lip itself.

Thin lips

• rely on the appropriate labiolingual position of the teeth, for their fullness and support
• Any slight change in the labiolingual tooth position makes an immediate change in the lip contour

Thick lips

• need lesser support from the artificial teeth and the labial flange

HEALTH OF THE LIPS

• examined for cracking, fissuring at the corners and ulceration

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These changes can be caused by

• vitamin B-complex deficiency
• Candida albicans
• Excessive overclosure of an existing denture
• Can be neoplastic condition.

Lip mobility

• Class 1-Normal
• Class 2-Reduced Mobility
• Class 3-Paralysis

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Patients with minimal lip mobility show very little of the anterior teeth

stroke victims may have paralysis of half the lip, leading to unilateral mouth droop and facial asymmetry

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• 1. Competent lips – lips are in slight contact when the musculature is relaxed
• 2. Incompetent lips – morphologically short lips which do not form a lip seal in a relaxed state
• 3. Potentially incompetent lips – normal lips , fail to form lip seal
• 4. Everted lips – hypertrophied lips with weak muscular tonicity

LIP SUPPORT

• Adequately supported
• Unsupported
• contour and appearance of the vermillion border usually are altered by tooth loss
• restoration of lip support and vermillion border width must be considered during placement of anterior teeth

If only tissues around mouth is wrinkled and rest of the face is normal then lack of support is suspected.

• If this lacking is due to too palatal positioning of anterior teeth it can be confirmed by adding wax
• too far anteriorly placed teeth to support the lip may cause leverage on maxillary denture causing loss of stability.
• Another way is by assessing nasolabial angle.

- If nasolabial angle is increased after wearing denture --means drooping of lip and loss of lip support occurs.

Palpation of masticatory muscles�

• Temporalis

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• Medial Pterygoid

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• Lateral Pterygoid

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• Masseter

Salivary Glands

• Palpate parotid and submandibular

salivary glands - bilateral technique.

• Normally should not be palpable.
• Induration and pain - signs of infection, blockage, immune system disorder or neoplastic process.
• non-tender parotid enlargement may occur with alcoholism, diabetes, Sjögren’s syndrome, eating disorders, HIV infection and various malignant/non-malignant states involving the salivary glands.

Mouth Opening

• Normal mouth opening is 40-45 mm
• Decrease is called as trismus.

Causes of trismus are: • Trauma

• Tumor
• Localized inflammation
• TMJ disorders
• Pericoronitis
• Myositis ossificans
• Scleroderma

RECOMMENDED SCREENING

EXAMINATION PROCEDURES FOR TMD

Temporomandibular disorders: diagnosis, management, education, and research.McNeill C, Mohl ND, Rugh JD, Tanaka TT

J Am Dent Assoc. 1990 Mar; 120(3):253, 255, 257 passim.

Temporomandibular Joint Evaluation

• The function of the TM joint evaluated using bilateral technique.
• Place the fingertips over the joint and have the patient open and close slowly move the jaw to the left and right and put the chin out.
• Look for deviations & deflections, Clicks, Pops,Crepitus, tenderness and limitations in opening.
• Crepitus is usually due to a tear in the disc or the posterior attachment which produces bone to bone contact of the mandibular condyle with the glenoid fossa.
• health of the TMJ is a key factor in the assessment of the ability of patients to cooperate with the dentist when jaw relation records are being made.
• Due to difficulty in mouth opening and closing, recording of the jaw relation is difficult.

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INTRAMEATAL AND PREAURICULAR EXAMINATION OF TMJ

Lateral palpation of tmj

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• Exert slight pressure on condyloid process with index figure.
• Palpate both sides together
• Register any pain/

tenderness

/irregularity in movement while closing or opening

• Co ordination between left and right TMJ should be noted

Posterior palpation

• Position little finger in external auditory meatus and palpate posterior surface of condyle during opening and closure.
• Palpation should be carried out in such a way that the condyle displaces the little finger when closing in full occlusion.

Auscultation

• done by stethoscope
• Types of clicking
• Initial movement –sign of retruded condyle in respect to disc
• Intermediate—sign of unevenness of condyle and disc
• Terminal – occurs most commonly results in condyle being moved too far anteriorly on maximum opening
• Reciprocal – occurs during opening and closing and expressed in coordination between disc and condyle

Lymph nodes

• Most commonly examined lymph nodes include submental, submandibular, pre and post-auricular cervical and axillary lymph nodes.
• To examine the head and neck lymph nodes and other soft tissue of the oral region, the clinician must palpate the area gently to look for tenderness or enlargements.

• Normal lymph nodes are either not palpable, or may feel like a pea or lentil, and are not tender when touched.
• Abnormal lymph nodes are generally larger, may be tender, and can be an indication of an inflammation or that drainage of infection has occurred.
• A non-tender enlargement may indicate cancer or lymphoma.

Speech Evaluation

Patients with speech impediments require special attention in setting of anterior teeth and forming the palatal portions of the upper denture.

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Speaking activity may be classified as

• Normal
• Affected

Intraoral examination

Mucosa

lines body cavities and passages which communicate directly or indirectly with the outside of the body : MUCOUS MEMBRANE

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Masticatory Mucosa

Lining Mucosa

Specialised Mucosa

Alveolar Ridges,the attached gingiva and hard palate.

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Generally keratinised and has a metabolic pattern

similar to gingival tissue

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has characteristic thickness,degree of keratinisation, lamina propria firmness and immovable attachment to underlying structure.

allows to determine the potential retention and stability

Covering of the lips and cheeks

Vestibular spaces

Alveololingual sulcus

Soft palate

Ventral surface of the tongue

Unattached gingiva found on the slopes of the residual ridges

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Normally devoid of a keratinized layer / NON KERATINIZED

Freely movable because of the elastic nature of the lamina propria

Covers-Dorsal surface of the tongue

Keratinized

includes specialized papillae on the surface of the tongue

Clinical examination of mucosa

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The oral mucosa should be examined carefully and the following features should be evaluated

• Color
• Texture
• Continuity
• Contour
• Thickness / Consistency

House Classification�

Color

Normal Mucosa : Coral Pink

May range from healthy pink to angry red

Pigmentaion – could be physiological or due to drug reactions

Redness - inflammation

Mechanical irritation - Ill-fitting denture

Chemical irritation

Systemic disease such as diabetes,

chronic smoking

Underlying infection – Bacterial, fungal or viral.

Condition of the mucosa – House

Class 1

Class 2

Class 3

Mucosa is examined for :

• -Normal reseliency
• -hard Unyielding
• -Displaceable
• -Spongy
• -hyperemic
• -hypertrophy

Thickness of mucosa

• Quality of mucoperiosteum vary in different parts of the arch.
• Variations in the thickness of the mucosa can cause difficulty to equalize pressure under denture and to avoid soreness.
• With ageing – decrease in thickness
• Edentulous mucosa of the elderly is frequently thin and tightly stretched and it blanches easily
• Thick mucosa leads to lack of stability ,less tissue tolerance and jaw relation will be difficult to obtain. In this case non anatomic teeth should be preferred.
• Inflamed and abused mucosa should be treated first, etiology should be determined and stopped before impression procedure.

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Oral mucosal lesions

• Wickham’s striae, Oral Lichen Planus – Erosive lesions and subsequent scarring in the buccal shelf area limit denture extension in this region and make it difficult for some patients to tolerate their dentures.
• Pemphigoid – Chronic ulceration with subsequent scarring of the oral mucosa.

– Limited denture extensions compromising support, stability, retention and tolerance of complete dentures.

Chronic Candidiasis

• Mild - Low saliva flow, Candidiasis leads to increased numbers of fungal organisms
• Severe - leading to a high Candidiasis incidence of chronic Candidiasis. Angular cheilitis secondary to chronic Candidiasis.

Clinical Manifestations

• Burning and irritation of the denture bearing mucosa
• In addition the fungus is keratolytic, further compromising support and tolerance.

Treatment

• Topical antifungal therapy followed by relining of the dentures (Nystatin is the drug of choice. It can be dispensed as a cream, a powder or an oral lozenge).

FRENUM ATTACHMENTS

• Labial Frenum: Single band of fibrous connective tissue.

No muscle attachments.

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• Buccal frenum: Maybe one or two in number.

Buccinator, levator anguli oris, Orbicularis Oris muscle attachment in the maxilla.

House Classification

• Class1: muscle / frenal attachment is close to the vestibule & is considered low
• Class2: muscle/frenal attachment is higher & closer to crest of the ridge
• Class3: muscle/frenal attachment is too high and may interfere with retention of denture

Surgical intervention may be necessary

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Saliva

Both flow rate and viscosity important to denture success.

• Lubricates mucosa
• assists retention

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Classification�

Class 1 - Normal quality and quantity of saliva. Cohesive and adhesive properties are ideal

Class 2 - Excessive saliva, contains much mucous

Class 3 – Xerostomia. Saliva is mucinous.

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Quality

• Thin watery(Serous)
• Mucinous(mixed)
• Thick mucous ( Mixed)

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Quantity

• Normal
• Decreased
• Excessive

Saliva quantity

• Normal: ideal for denture retention.
• Normal salivary secretion is 1 ml/min (Zarb)
• 1000 to 1500 ml of saliva secreted per day
• 0.38 -/+ 0.21 ml/min Unstimulated
• 4.3 +/- 2.1 ml/min Stimulted (Budtz jorgensen)
• Excessive – affects retention by disrupting the border seal

-complicate impression making

-cause problem to patients wearing new dentures

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• Reduced – xerostomia, reduces retention & increased potential for tissues soreness
• Causes:
• 1)medication
• 2)radiation therapy in the region of the salivary glands
• 3)glands may be diseased or ducts may be blocked.
• 4)long term wearing of a complete maxillary denture
• 5)destruction of palatal gland due to pressure atrophy resulting from lost residual alveolar ridge support of the denture.
• Management :
• Design dentures to maximize retention and minimize displacing forces. Salivary substitutes or oral moisturizers

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SALIVA COLLECTION METHODS

• Draining Method:
• The subject is made to sit with the head bent down and mouth open to allow the saliva drip passively from the lower lip into the graduated sterile tubes.
• Saliva collected by draining is without any stimulation and is more reliable

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• Spitting Method:
• Saliva is allowed to accumulate in the floor of the mouth and the subject spits out it into the preweighed or graduated test tubes.
• advantage: can be used when the flow rate is very low and where evaporation of saliva has to be minimised.
• disadvantage: have some stimulatory effect - cannot be used for unstimulated saliva collection

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Priya, Y., & Prathibha, M. (2017). Methods of collection of saliva-A Review.International Journal of Oral Health Dentistry; July-September 2017;3(3):149-153

• Suction Method:
• Saliva allowed to accumulate in the floor of the mouth and aspirated continuously using micropipettes, syringes, saliva ejector or an aspirator.

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• Swabbing Method:
• synthetic gauze, pre-weighed swab or cotton pad introduced into mouth, at the orifices of major salivary glands.
• asked to chew such that the sponge gets soaked with the saliva.
• Saliva soaked sponge is removed and placed in a sterile test tube
• less reliable method but helps in the assessing level of oral dryness.
• mainly used in the monitoring of drugs, hormones or steroids

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Arch size

Class 1 – Large (best for retention and stability)

Class 2 – Medium (good for retention and stability but not ideal)

Class 3 - Small (difficult to achieve good retention and stability)

Shape

• Smooth
• Irregular
• Knife edged
• Flat

Arch form – House Classification

Class 1 :square

Class 2 :tapering

Class 3 :ovoid

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• The arch form affects support of the denture.
• It helps in proper stock tray selection as well as teeth selection and arrangements

RIDGE CONTOUR�

Maxillary

Class 1- square to generally round

Class 2 - tapering or v-shaped

Class 3 - flat

Ideal is high ridge with flat crest and parallel side – this gives max support and stability

Mandibular

Class 1 : Inverted U- shaped, Parellel walls ,high to medium height with broad crest.

Class 2 : Inverted U-shaped with short flat crest

Class 3 : Unfavourable

or

Inverted w

Short inverted v

Ridge with undercut (results from lingual or buccally placed teeth)

Undercuts

• On maxilla- present on anterior ridge and lateral to

tuberosities.

• one of the bilateral tuberosity undercut should be removed

• ON MANDIBULAR RIDGE- only undercut that can pose a real problem is prominent, sharp mylohyoid ridge.
• Management- surgical reduction and reattachment of mylohyoid muscle .
• They cause difficulty in denture removal & insertion;

abrasion of mucosa & pain.

Do not aid in retention and may cause some loss of border seal.

Interarch space

Class 1 - Ideal interarch space to accommodate the artificial teeth (min 16-18mm)

Class 2 - Excessive interarch space

Class 3 - Insufficient interarch space

Interarch space is usually difficult to determine during initial period of diagnosis unless the cast is properly mounted on the articulator, but an early attempt should always be made for proper diagnosis

Examination of inter arch space

• Ask the patient to rest the jaw and carefully part the lips to examine the distance. To stabilize the mandible dentist should rest his thumb under patients chin. (Sharry)
• Inter ridge distance should be examined around entire arch as it varies in different part of the ridge. Most frequent problem is seen in retro molar tuberosity area.
• Small inter ridge distance in contrast to larger distance

Enhances retention and stability (sharry)

CLINICAL SIGNIFICANCE

• Retention is enhanced because the tongue contacting the lingual and palatal surfaces of denture more completely fills the oral cavity providing an excellent seal
• Stability increases because occlusal surfaces of the teeth are more close to the ridge --- minimizes undesirable tilt and tongue forces.
• Disadvantage of small ridge distance is difficulty in teeth arrangement.
• Large inter ridge distance caused by the marked resorption of the ridge is a threat to retention and stability.

Ridge parallelism

• Class 1 Both ridges are parallel to occlusal plane
• Class 2 Mandibular ridge is divergent from occlusal

plane anteriorly.

• Class 3 Maxillary ridge is divergent from occlusal plane or Both the ridges are divergent occlusally.

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To observe this relation tell patient to position jaw at VDO and part the lip with finger and mouth mirror or mounted diagnostic cast can be used.

• Denture stability is enhanced by parallel ridge. In Natural dentition the ridges are parallel

• To overcome un-parallelism implant supported denture should be considered.

Ridge relation

The positional relation of the mandibular ridge to the maxillary ridge- GPT.

Maxilla resorbs- upward and inward

Mandible resorbs- downward,

forward, and laterally

Angle classified ridge relationship

• Class I Normal
• Class II Retrognathic
• Class III Prognathic

THE HARD PALATE

Shape of hard palate can be:

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• U shaped -Most favorable for retention and stability.

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• V shaped- Not very favorable. Slight movement of the denture breaks the seal & loss of retention. May be associated with a tapered arch

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• Flat or shallow vault- Reduced resistance to lateral and rotatory forces. Usually accompanied by resorbed ridge.

Maxillary tuberosity

Syn : Alveolar Tubercle

• Normal
• Bulbous
• Pendulous
• Undercut.

It forms the most important area of support as they are less likely to resorb.

Soft palate

Soft palate classification (Winkler)

• Class 1 - Soft palate rather horizontal with minimum muscular activity. tfere PPS area is maximum and not deep. Most favorable for retention more than 5mm of movable tissue is available for post-damming

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• Class 3 indicates most acute contour of soft palate with hard palate. Usually seen in V shaped palatal vault. PPS area is smaller and deeper. Least favorable for retention
• Class2 in between class 1 and class 3

Palatal sensitivity(gag reflex)

House classification :

• Class 1 - Normal response to palpation
• Class 2 - Subnormal response(hyposensitive)
• Class 3 - Supernormal response (hypersensitivity)

Management :

Construct dentures to maximise retention and minimise displacing forces.

Use ’condition’ appliance eg fully extended base for home use.

Psychological assessment if indicated

Palatal throat form

• Class I:

Large and normal in form -immovable band of tissue 5- 12mm distal to line drawn across the distal edge of the tuberosities.

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• Class II:

Medium size and normal in form- resilient band of tissues 3-5mm distal to line drawn across the distal edge of the tuberosities.

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• Class III:

Accompanies small maxilla. Soft tissues turn down abruptly 3-5mm anterior to the line drawn across the distal edge of the tuberosities.

Lateral throat form

Defined By Neil –Contour of the hard lingual surface of the mandibular ridge in the molar area and the velum like tissue distal to the mylohyoid ridge in the retromylohyoid fossa as it functions under the influence of the tongue

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Bounded by

Anteriorly - Mylohyoid

muscle,

Laterally – Pear shaped pad

Posterolaterally – Superior Constrictor Muscle

Posteromedially –

Palatoglossus Muscle

Medially - Tongue

Use a mouth mirror, often the same length and width as a denture flange

-Place it into the lateral throat

area

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-Patient is instructed to make some moderate tongue movements

head of the mirror is usually round, and the most common sizes used are the No. 4 Ø (18 mm) and No. 5 (Ø 20 mm)

• Class1:

This form indicates that the anatomical structures will accommodate a fairly long and wide flange

Deep : 0.5 inch space exists between mylohyoid ridge and the floor

Thickness of the border – usually 2-3mm thick

But thicker border of 4-5mm should be used for better seal if the border is flat

• Class 2

Is about half as long and narrow as the class1 and about twice as long as a class3

Moderate : Less than 0.5 inch space exists

Most edentulous mouth have class1 and class2 lateral throat forms,

• Class3

Shallow : Mylohyoid fold is at the same level as mylohyoid ridge.

Retention is difficult

Tongue Position : Wright classification

Tongue size – House Classification

Class I: Normal in size, development, and function. Sufficient teeth present to maintain normal form and function.

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Class II: teeth absent long enough to permit a change in the form and function of the tongue.

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Class III: excessively large tongue. Teeth absent for extended period of time- abnormal development of the size of the tongue. Insufficient dentures can lead to development of class 3 tongue.

Tori

Torus palatinus & lingual tori frequently present

Torus palatinus: range from a small prominence in the midline to one that covers the entire hard palate.

Adequate relief must be planned.

Lingual tori: interfere with denture construction & unless very small should be surgically removed.

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Class I - Tori absent or minimal in size. Do not interfere with denture construction.

Class II – Moderate size. Mild difficulties in denture construction and use. Surgery not required.

Class III – Large in size. Compromise fabrication & function of dentures. Requires surgical recontouring or removal.

DIGNOSTIC AIDS

• STUDY CASTS
• Accurate study casts should be made, duplicated, and articulated.
• When the mouth is edentulous and surgical intervention is necessary, the outline for surgical operation can be marked.
• The altered casts can serve as a guide for the dental surgeon in the removal of

tissue which would interfere with the success of new dentures.

• Helps dentists avoid a potential problem
• Aid in determining the
• inter ridge space,
• ridge relationships,
• ridge shape and form
• cannot be adequately determined by clinical examination alone

PRE EXTRACTION RECORDS

• Old diagnostic casts: determining both size, position & arrangement of teeth.
• Old radiographs: determining tooth size & bony change.
• Photographs: relay information regarding tooth size, position & display during facial expressions.

Forms an effective tool in achieving proper esthetics & patient satisfaction

ROENTGENOGRAMS

• The anatomic contour and general character of the bone are observed as well as cystic formations and atrophy.
• Roentgenograms of edentulous dental arches reveal the location of stresses

under old dentures, the thickness of the mucosa, the rapidity of resorption of the

basal bone, and the character of the bone.

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• Radiographs is useful in the following instances : -

1. Bone pathosis, cysts, tumors.

• 2. Retained roots or teeth.
• 3. Bony fractures.
• 4. Soft tissue thickness.
• 5. Extent of bone resorption.
• 6. Thickness of body of mandible.
• 7. To locate mandibular canal & it’s proximity to ridge crest.
• 8. To locate maxillary sinuses.
• 9. To plan surgeries.
• 10. Remaining bone density and quality.
• 11. As treatment records.
• 12. For patient education.

• Panoramic radiographs also aid in determining the amount of ridge resorption.

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•  Wical & Swoope advocated measuring the distance from the inferior border of the mandible to the inferior margin of the mental foramen and then multiplying it by 3, the resultant product is a reliable estimate of the original alveolar ridge crest height

�Classification of ridge�resorption (Wical & Swoop)�

• Class I - mild resorption-Loss of up to 1/3rd original height
• Class II - Moderate resorption-1/3rd to 2/3rd loss of height
• Class III - Severe resorption-2/3rd or more loss

Bone quality (Branemark, Zarb) as seen on radiographic examination

• Class I- homogeneous compact bone.
• Class II – thick cortical/dense trabecular
• Class III – thin cortical/dense Trabecular
• Class IV – thin cortical/Fine Trabecular

Bone quantity�

• According to Branemark
• Class A - normal bone
• Class B - loss of alveolar bone
• Class C - complete loss of alveolar bone
• Class D - Resorption of basal bone
• Class E - Rudimentary bone present (advanced loss of basal bone)

TREATMENT PLANNING

• The treatment plan should specify regarding the treatment procedures,operating time,laboratory time, calender time & fees such that patient informed consent regarding the same can be obtained.
• Treatment plan for completely edentulous patients includes:
• Adjunctive care
• Pt education &motivation
• Elimination of infection.
• Elimination of pathoses.

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• Treatment of abused tissues.
• Tissue conditioning.
• Nutritional counseling.
• Prosthodontic care –Conventional complete denture.
• implant supported complete denture

• In CD treatment planning , the following must be considered
•  Basic criteria:
• (a) Retention (b) Stability (c) Rigidity of prosthesis (d) Good masticatory function (e) Biocompatibility of dental materials.
•  Esthetics and other factors for physical & psychological comfort
•  Cost of maintenance also to be considered

Adjunctive care�

• Tissue conditioning-
• Finger massage
• Medications
• Resting of the soft tissues
• Soft reline changes
• Pre prosthetic surgery
• Nutritonal supplements

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PT EDUCATION &MOTIVATION�

• Inform patient of their dental health and significance
• Making patient understand the significance of edentulism
• Match patients expectations with reality of treatment potential
• Explain nature, use and shortcomings of prosthesis
• Identify alternative treatment plan
• It facilitates:

 acceptance of treatment

 acceptance of fees

 continuing care

SURGICAL CORRECTIONS

• 1)correction of hyperplastic ridge tissue ,epulis fissuratum, papillomatosis, hyperplastic pendulous tuberosity.
• Indication - no response to nonsurgical rx procedures.
• - Interferes with stability . excision of the tissues with vestibuloplasty - electro surgery.
• 2)frenal attachments-maxillary labial frenum broad fibrous band,lingual tongue tie,prominent buccal freni
• • Indications—near to crest of ridge. - Frenectomy.
• 3)papillary hyperplasia - small lesion with sharp curettes electro surgery. - Large lesion split thickness supra periosteal flap.
• 4)vestibuloplasty -restores the ridge height by lowering the muscle attachments & attached mucosa.

OSSEOUS ABNORMALITIES

• Ridge undercuts.
• Prominent mylohyoid &Internal oblique ridge-surgical recontouring repositioning of muscle attachment.
• Prominent genial tubercle-surgically removed & genioglossus muscle sutured to geniohyoid muscle.
• Bony tuberosities
• Residual ridge sharp, spiny.
• Torus palatinus.
• Torus mandibularis.
• Discrepancies in jaw size.
• Mental foramen with sharp extended margins.
• Ridge augmentation.

PROSTHODONTIC CARE

• Conventional complete denture.

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• Implant supported.
• Previous h/o failures with conventional complete dentures
• Good health
• Affordable.
• Patient with compromised motor skills,
• Advanced residual ridge resorption

• TREATMENT PLANNING

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• Teeth selection

Shade ,mold and material should be selected

• Denture base material and shade
• Anatomic palate-yes/no
• Charecterization-establish the stains mark the areas
• List items to improve on in new dentures
• List items not to be changed in new dentures.

����PROSTHODONTIC DIAGNOSTIC INDEX:�American college of Prosthodontics (ACP)�

• four diagnostic criteria
• 1. Mandibular bone height
• 2. Maxillomandibular relationship
• 3. Maxillary residual ridge morphology
• 4. Muscle attachments

Bone Height

• Bone Height: Mandible only
•  Type I (most favorable): residual bone height of 21 mm or greater
• measured at the least vertical height of the mandible.
•  Type II: residual bone height of 16 to 20 mm measured at the
• least vertical height of the mandible.
•  Type III: residual alveolar bone height of 11 to 15 mm measured
• at the least vertical height of the mandible.
•  Type IV: residual vertical bone height of 10 mm or less measured
• at the least vertical height of the mandible.

• The continued decrease in bone volume affects:
• 1) denture-bearing area;
• 2) tissues remaining for reconstruction;
• 3) facial muscle support/attachment;
• 4) total facial height
• 5) ridge morphology.

Maxillomandibular Relationship

• Class I (most favorable): Maxillomandibular relation allows tooth position that

has normal articulation with the teeth supported by the residual ridge.

• Class II: Maxillomandibular relation requires tooth position outside the normal

ridge relation to attain esthetics, phonetics, and articulation (eg, anterior or

posterior tooth position is not supported by the residual ridge; anterior vertical

and/or horizontal overlap exceeds the principles of fully balanced articulation).

• Class III: maxillomandibular relation requires tooth position outside the normal
• ridge relation to attain aesthetics, phonetics, and articulation (i.e crossbite anterior or posterior tooth position is not supported by the residual ridge).

Residual Ridge Morphology:�Maxilla Only

• Type A (most favorable)
• Anterior labial and posterior buccal vestibular depth that resists vertical and horizontal movement of the denture base.
• Palatal morphology resists vertical and horizontal movement of the denture base.
• Sufficient tuberosity to resist vertical and horizontal movement of the denture base.
• Hamular notch is well defined to establish the posterior extension of the denture base.
• Absence of tori or exostoses.

Type B

• Loss of posterior buccal vestibule.
• Palatal vault morphology resists vertical and horizontal movement of the denture base.
• Tuberosity and hamular notch ,are poorly defined, compromising delineation of the posterior extension of the denture base.
• Maxillary palatal tori and/or lateral exostoses are rounded

and do not affect the posterior extension of the denture base.

Type C

• Loss of anterior labial vestibule.
• Palatal vault morphology offers minimal resistance to vertical and horizontal movement of the denture base.
• Maxillary palatal tori and/or lateral exostoses with bony undercuts that do not affect the posterior extension of the denture base.
• Hyperplastic, mobile anterior ridge offers minimum support and stabilityof the denture base
• Reduction of the post malar space by the coronoid. process during mandibular opening and/or excursive movements.

Type D

• Loss of anterior labial and posterior buccal vestibules.

 Palatal vault morphology does not resist vertical or horizontal movement of the denture base.

• Maxillary palatal tori and/or lateral exostoses" (rounded or undercut) that interfere with the posterior border of the denture.
• Hyperplastic, redundant anterior ridge. Prominent anterior nasal spine

Muscle attachments: mandible only

•  Type A (most favourable)
• -Attached mucosal base without undue muscular impingement during normal function in all regions.
•  Type B
• -Attached mucosal base in all regions except labial mentalis muscle attachment near crest of alveolar vestibule ridge.
• Type C
• -Attached mucosal base in all regions except anterior buccal and lingual vestibules-canine to canine
• -Genioglossus and mentalis muscle attachments near crest of alveolar ridge.
•  Type D
• -Attached mucosal base only in the posterior lingual region.
• -Mucosal base in all other regions is detached.

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Condition requiring preprosthetic surgery

• Minor soft tissue procedure
• Minor hard tissue procedure
• Implants-simple
• Implants with bone graft-complex
• Correction of dentofacial deformities
• Hard tissue augmentation
• Major soft tissue revisions

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Limited inter-arch space

• 18-20mm
• Surgical correction needed
• Tongue anatomy
• Large(occludesinterdental space)
• hyperactive

Modifiers

• Oral manifestation of systemic disease
• Psychosocial
• TMD symptoms
• History of paresthesia/ dysesthesia
• Maxillofacial defects
• Ataxia
• Refractory patient

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������Classification System for Complete�Edentulism

• class I
• Residual bone height of 21 mm orgreater measured at the
• least vertical height of the mandible on a Panoramic
• radiograph.
• Residual ridge morphology resists horizontal and
• vertical movement of the denture base- Type A maxilla.
• Location of muscle attachments that are conducive to denture base
• Stability and retention-Type A or B mandible.
• Class I maxillomandibular relationship

Class II

•  Residual bone height of 16 to 20 mm measured at the least vertical height of the mandible on a panoramic radiograph.
•  Residual ridge morphology that resists horizontal and vertical movement of the denture base- Type A or B maxilla.
•  Location of muscle attachments with limited influence on denture base stability and retention- Type A or B mandible.
•  Class I maxillomandibular relationship.
• Minor modifiers, psychosocial considerations, mild systemic disease with oral manifestation

Class III

• Residual alveolar bone height of 11 to 15 mm measured at the least vertical height of the mandible on a panoramic radiograph.
• Residual ridge morphology has minimum influence to resist horizontal or vertical movement of the denture base; Type C maxilla.
• Location of muscle attachments with moderate influence on denture base stability and retention; Type C mandible.
• Class I,II ,III maxillomandibular relationship

• Moderate psychosocial consideration and/or moderate oral manifestations of systemic diseases or conditions such as xerostomia
• TMD symptoms present.
• Large tongue (occludes interdental space with or without hyperactivity)
•  Hyperactive gag reflex

Class IV

•  Residual vertical bone height of 10 mm or less measured at the least vertical height of the mandible on a panoramic radiograph.
•  Residual ridge offers no resistance to horizontal or vertical movement; Type D maxilla.
•  Muscle attachment location that can be expected to have significant influence on denture base stability and retention; Type D or E mandible.
•  Class I, II, or III maxillomandibular relationships

PROGNOSIS

• Provides an indicator to the course of disease or treatment(GOOD/FAIR/POOR)
• In complete denture the prognosis should indicate the number of years the patient can successfully use the prosthesis with satisfaction.

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FACTORS CONSIDERED IN PROGNOSIS

SOAP summary

• S- Subjective
• What the patient tells C/C, past medical history etc.
• O-Objective
• What we see on extraoral examination face form , symmetry, profile etc.
• A –assessment
• Based on ACP classification
• P –Plan
• treatment options,materials used and the steps in fabrication

CONCLUSION

• Diagnosis involve examination of the patient, right from he enters the clinic,beginning from the collection of personnel information of the patient clinical history taking and then extra & intra oral examination.
• • Subjecting the patients to required investigations,to confirm the diagnostic findings ,and referring patients to other specialist on requirement.
• • On the basis of diagnostic findings the rx plan is framed.
• • Diagnosis and rx planning form the first important milestone for the successful accomplishment of the rx &favorable prognosis as the potential problems are identified & treatment plan is framed accordingly

References

1. Boucher’s: Prosthodontic treatment for edentulous patients, 11th edn.
2. Winkler: Essentials of complete denture prosthdontics, 2nd edn.
3. Rahn & Heartwell: Textbook of complete denture, 5th edn.
4. A Primer on complete denture prosthodontics – K . CHANDRASHEKHARAN NAIR
5. The dental clinics of North America, Jan 1996;40(1)
6. MM HOUSE MENTAL CLASSIFICATION REVISITED : INTERSECTION OF PARTICULAR PATIENT TYPES & PARTICULAR DENTIST’S NEEDS(J Prosthet Dent 2003;89:297-302.) SIMON GAMER,TUCH,GARCIA
7. Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension.Bruce Bavitz

• 8.Lakhyani, Rohit and Shivaraj S Wagdargi. “Saliva and its Importance in Complete Denture Prosthodontics.” (2012).

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• 9.McCord, A. A. Grant, ”Identification of complete denture problems: a summary” British
• Dental Journal 2000; 189: 128–134

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• 10McGarry, T. J., Nimmo, A., Skiba, J. F., Ahlstrom, R. H., Smith, C. R., & Koumjian, J. H. (1999). Classification System for Complete Edentulism. Journal of Prosthodontics, 8(1), 27–39.

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• 11.Pandey S, Datta K. Prosthodontic management of a completely edentulous patient with unilateral facial paralysis. J Indian Prosthodont Soc 2007;7:211-3

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• 12.Haralur SB. Clinical Strategies for Complete Denture Rehabilitation in a Patient with Parkinson Disease and Reduced Neuromuscular Control. Case Rep. Dent. [Internet] 2015;2015:352878.

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Cross References

1. Haralur SB. Clinical Strategies for Complete Denture Rehabilitation in a Patient with Parkinson Disease and Reduced Neuromuscular Control. Case Rep. Dent. [Internet] 2015;2015:352878.
2. Journal of Clinical and Diagnostic Research. 2015 Dec, Vol-9(12): ZE01- ZE04  Prosthodontic Management of Hypohidrotic Ectodermal Dysplasia with Anodontia: A Case Report in Pediatric Patient and Review of Literature - Ann Med Health Sci Res. 2013 Apr-Jun; 3(2): 277–281
3. Gen Dent. 2008 May-Jun;56(4):e12-6.Complete denture prosthodontics for a patient with Parkinson's disease using the neutral zone concept: a clinical report. Makzoume JE 164
4. Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension.Bruce Bavitz
5. JPD vol35, Issue 2, February 1976, Pages 192-201.Prosthetic support for unilateral facial paralysis. Larsen & carte 163

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Thank you